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Incision and drainage preferable to oral antibiotics in acute paronychial nail infection?
  1. Jonathan Shaw, Specialist Registrar,
  2. Richard Body, Clinical Research Fellow
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; s.carley1btinternet.com

    Abstract

    A short cut review was carried out to establish whether incision and drainage or antibiotics was best for acute paronychia. No relevant papers were found using the reported search. There is currently no evidence that oral antibiotics are any better or worse than incision and drainage for acute paronychiae.

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    Report by Jonathan Shaw, Specialist RegistrarChecked by Richard Body, Clinical Research Fellow

    Three part question

    In [a patient with an acute paronychial nail infection] is [incision and drainage superior to oral antibiotics] in [settling infection]?

    Clinical scenario

    A healthy 22 year old lady attends the emergency department complaining of a painful, red finger, which she says has come on over a couple of days. Examination reveals erythema to the side of her fingernail with a suggestion of a slight yellow centre. You diagnose an acute paronychia, but wonder whether to prescribe her a course of oral antibiotics or formally incise and drain the suspected collection.

    Search strategy

    Medline 1966 to February 2005 using the OVID interface: [(exp Paronychia/OR paronychia$.af. OR felon$.af. OR whitlow$.af. OR (finger ADJ infect$).mp. OR (digit$ ADJ infect$).mp. OR (nail ADJ infect$).mp.] AND [incision adj drainage.mp. OR drainage.af. OR exp drainage/OR incis$.af. OR i&d.af. OR surg$.af.)] AND [antibiotic$.af. OR exp Anti-bacterial agents/OR antibacterial$.af. OR antimicrobial$.af. OR antiinfective$.af. OR anti-biotic$.af. OR anti-microbial$.af. OR anti-infective$.af.]. Embase 1974 to February 2005: [exp paronychia/OR paronychia$.af. OR felon$.af. OR whitlow$.af.] AND [exp incision/OR incis$.af. OR incision.af. OR drainage.af. OR exp surgical-drainage/OR exp percutaneous-drainage/] AND [antibiotics OR exp antibiotic-agent/OR exp anti-biotic-therapy/OR exp antiinfective agent/OR antibacterial$.af. OR antimicrobial$.af. OR antibiotic$.af. OR anti-biotic$.af. OR anti-bacterial$.af. OR anti-infective$.af. OR anti-microbial$.af.]. Cochrane Library 2005 Issue 1: Paronychia* OR felon* OR whitlow*.

    Search outcome

    Medline: 73 papers, none relevant. Embase: 61 papers, none relevant. Cochrane: 72 papers, none relevant.

    Relevant paper(s)

    There were no relevant papers.

    Comment(s)

    It seems to be generally accepted practice in emergency medicine that any paronychial infection with an apparent area of pus requires incision and drainage, which is painful for the patient and time consuming for the clinician. In contrast, we regularly see patients who have failed treatment with antibiotics prescribed by other departments or primary care. There is currently no evidence that surgical management confers any advantage over oral antibiotics for the treatment of paronychiae. A well-designed comparative trial may help to elucidate whether the traditional surgical approach actually leads to superior outcome. Currently our practice is to incise and drain if pus is present.

    CLINICAL BOTTOM LINE

    There is currently no evidence that oral antibiotics are any better or worse than incision and drainage for acute paronychiae.

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